2016_0907 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) � � �
MA[LING ADDRESS: � � v�''� �� �'• 4 �� Y"���-�'�'��;�
CONTACT PERSON/PHONE:
LOCATiON OF SERVICE: lddZ �
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
duced Pressure Principle I Reduced Pressure Principle-Detector
�� � ouble Check Valve '��1Double Check-Detector
1PressurcVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
(�
Manufacturer ���/� S Model Number �a � �� � Size�'�
,,�?
Located At �✓�'�'� t'�•� d� Serial Number � �
Is the assembly installed in acc rdance with manufacturer recommendations and/ar local codes? ��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
� Relief Valve Air Inlet Check Valve
� 1 st Check 2nd Check
� p�
Held at��`v ps' Held at�psid Opened at Opened at Held at
Initial Test Closed Tigh '�%' Closed Tig tj,1�'I� psid ps�d psid
Leaked'� I Leakedf" Did not open I��' Did not open f ' Leaked�� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight IJ Closed Tight 1 psid psid psid
Test gauge used: Make/Model ���r �I�.t. � SN:� � �-���� �
Date Tested for Accuracy: ���� �� �
Remarks:
The above is certified to be true at the time of testing.
�l ��.,�
FirmName`�i t'`�����f� � Firm Address �'���x����S� �� 6��
Certified Tester(print) ��l'���s��� Certified Tester(signature) �` ` ���-
Firm Phone#��� ��� �-'�,d Cert.Tester N� �V 3f �� � Dat - �
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy